The City of Birmingham is pleased to offer automated payments. Payments will be processed
via ACH and deposited directly into a checking account specified by the landlord. To begin the
setup process, simply complete the authorization form below and either
e-mail, fax, or mail to:
City of Birmingham-Community Development Department
Attn: Emergency Rental Assistance
710 North 20
Street, Room 1000
Birmingham, AL 35203
(205) 254-2717 fax
Authorization Agreement:
I hereby authorize The City of Birmingham to initiate automatic deposits to my account at the
financial institution named below.
Landlord Information (Please Print)
Company Name: ___________________________________________
Contact Person: ____________________________________________
Street Address: _____________________________________________
City, State, Zip: _____________________________________________
Telephone Number: __________________________
(Email notification of payment will be sent): email: ___________________________________
Banking Information: (Please Print)
Name of Financial Institution:
Routing Number (9 digits): __________________________________________
Account Number: ___________________________
I certify that the information I provided is correct and that I am an authorized signer or designate for the
account provided.
Name(s) ____________________________________________________
(Please Print)
Date______________ Signature ________________________________
click to sign
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